Psychological Therapies

Seema Malhotra Excerpts

Wednesday 16th October 2013 Westminster Hall

[Mike Thornton (Eastleigh) (LD)]

I am glad to follow my hon. Friend the Member for Halesowen and Rowley Regis (James Morris) and the hon. Member for Strangford (Jim Shannon), whose points were particularly relevant. I shall try not to repeat them too often in my speech—that might mean reducing its length slightly, people will be pleased to hear.

When I was first elected, a new aspect of my life was the size and complexity of the casework that came my way. Much of it I expected and was familiar with, having been a councillor, but the one facet that surprised—no, shocked—me was the obvious failure in our duty to those with mental health issues. The next surprise was to discover that, in fact, the situation has improved over the past few years, and for that I pay tribute to the Minister, my hon. Friend the Member for North Norfolk (Norman Lamb), and his predecessor, my right hon. Friend the Member for Sutton and Cheam (Paul Burstow).

Today, we have the news that Dr Martin Baggaley, commenting on the results of a BBC freedom of information request, said that we are in “a real crisis” regarding the provision of mental health beds in England. My hon. Friend the Member for North Norfolk, the Minister, is reported by the BBC to agree that that is unacceptable.

At least, however, the BBC was able to obtain figures for the number of beds that have been lost. What would the response have been had the local trusts said, “Sorry, we don’t keep such figures. We have no idea of the number of beds available”? In another possible scenario, one of us asks the Secretary of State for Health, “What is the waiting time for the treatment of breast cancer or leukaemia?”, but the answer is, “I don’t know and I can’t find out.” Would not the whole House erupt in outraged uproar? Would not the press ask how proper provision for those patients can be provided in such circumstances?

Without adequate data and reporting, the needs of millions of ill people cannot be addressed—people with mental health issues. Without decent information, resources cannot be allocated correctly, results properly analysed or effective treatment provided. Yet for much of mental health provision, there is insufficient knowledge of whom we are treating, how we are treating them and how long they are waiting for treatment. As my hon. Friend the Member for Halesowen and Rowley Regis mentioned, we do not have minimum waiting times for much psychological therapy.

Few data are collated for the national policy framework. The data that we have focus on IAPT services and the rates for early mortality. My hon. Friend mentioned how early treatment of mental health problems can stop far worse developments, but without proper data we cannot understand that.

[Seema Malhotra (Feltham and Heston) (Lab/Co-op)]

The hon. Gentleman is making an important point about early intervention in mental health conditions. Does he agree that early intervention does not just stop an individual from cascading to the point at which their life becomes dysfunctional, but has a tremendous economic impact in preventing time off work and the difficulties that that causes for employers?

--- Later in debate ---

[Andrew Selous]

As colleagues have already stated, data on the type of therapies available under IAPT show that couple therapy is available in less than a quarter of cases. The data came from the “National Audit of Psychological Therapies for Anxiety and Depression, National Report 2011”, so they are official. The figure for couple therapy is only 24.6%, while interpersonal therapy is available in under half, or 48.3%, of the settings in which provision is made. For psychodynamic and psychoanalytic therapy, the figure is under 40%, at 39.8%, whereas cognitive behavioural therapy is available in 94.9%—just under 95%—of cases.

Those figures demonstrate the significance of CBT, which for some people with mental health issues is absolutely the right treatment, but it is important to realise that CBT is clearly not the appropriate treatment for all those with mental health conditions. We should also remember that all those therapies are approved and recommended by NICE, and the evidence shows that all such treatments are effective for the right patients.

I am particularly concerned that the benefits of a relational approach to the treatment of depression are not being realised and that, in many cases, individual CBT counselling is given where it is not appropriate. I want to tell a true story of one young couple’s experience of interacting with the IAPT programme. Figures and sums of money give the broad picture—they are our stock in trade as Members of Parliament—but they are a bit high-level and do not capture the essence of mental health provision on the front line.

Let me tell the story of Polly and Mark—to protect their anonymity, those are not their real names—who experienced considerable challenges in having two children, with several miscarriages and a stillbirth. Polly became very low and left her successful career. The hon. Member for Feltham and Heston (Seema Malhotra) has already pointed out the cost to the economy when people have mental health issues. Polly’s husband, Mark, had a very difficult childhood, and he was badly affected by his parents’ violent and stormy relationship.

When Polly and Mark’s youngest child was two, Polly confessed that she had had an affair seven years earlier, which left her feeling guilt and shame long after it ended. On learning that, Mark was utterly devastated by the revelation and fell into a deep depression, with unmanageable rages during which he threatened to kill the other man. Polly developed severe headaches, so she went to her GP and was sent for tests. On finding nothing wrong, the GP recommended that Polly have individual counselling focusing on the stillbirth four years previously. After being unable to work and having three weeks of sleepless nights, Mark also visited his GP. Mark was referred to a psychiatrist, who diagnosed him as suffering from acute depression and prescribed him antidepressants.

The couple were acutely conscious that their relationship was about to break down. Not having been offered any form of couple therapy by IAPT, they approached a voluntary sector service, and for six months, they went to weekly couple therapy. At the same time, they were offered cognitive behavioural therapy through IAPT. They believed that the problem was their relationship, but health professionals clearly thought that the depression needed treatment. In couple therapy, Polly was able to share her anxieties about her parents’ divorce and about how she did not want her children to suffer as she had. As the couple therapy progressed, Mark and Polly became more open with each other and began to understand how their relationship problems were a product of both recent and past difficulties.

An important point is that that couple therapy—it was not provided through IAPT; Mark and Polly had to go to the voluntary sector for it, because IAPT had offered them CBT that they did not need—was voluntary help that lasted for six months. My concern is that IAPT provision, whether of CBT or other measures, is often given for only a short period, which is not always appropriate or likely to be successful in such cases.

That true story illustrates powerfully why we need to look again at the IAPT programme, excellent though much of it is, and to take a relational approach to many of the issues where appropriate. I hope that it has been helpful to Members to put that real-life case study on the record.

Academic studies show why what I have said is important and matters. Evidence reveals links between relationship quality, depression and re-employability. For example, a meta-analysis conducted by McKee in 2005 concluded that lack of social support by partners in a relationship has negative impacts on the physical and psychological health of the unemployed person and is especially associated with more frequent development of psychosomatic symptoms, stress and depression.

The all-party parliamentary group on strengthening couple relationships, which I chair, and the newly formed Relationships Alliance published only last week a report that said that relationships were the missing link in public health. That report showed that relationship quality is often a key determinant of health and well-being, and that it has strong links with the ability to deal well with cardiovascular disease, obesity, alcohol misuse and mental health issues. All those issues link up, and strengthening the health of couple relationships is often right at the heart of them.

If we look at what has happened since the IAPT programme began—I understand that it receives funding of about £400 million a year—we can see that the investment has been very much towards cognitive behavioural therapy, with interpersonal psychotherapy, counselling for depression, brief dynamic therapy and couple therapy the poor relations in the area.

In a written parliamentary question, answered on 8 January 2013 and printed in volume 556, column 258, of the Official Report, we learn that of 1,225 sessions in 2012-13 only 99 were for couple therapy, whereas 459 were for CBT low-intensity therapy and 322 for CBT high-intensity therapy. If we look at the period from 2008-09 all the way through to the projections for 2013-14, we will see that of nearly 8,000 different sessions—7,958 to be precise—only 297 were for couple therapy. The story that I have just given of Polly and Mark shows that such sessions are needed up and down are country and can indeed make a significant difference.

[Seema Malhotra]

The hon. Gentleman is making a powerful speech on the importance of having a relational base to services. In my own constituency of Feltham and Heston, I visited a service that was started a year ago by the National Society for the Prevention of Cruelty to Children. It works with children who have parents with drug and alcohol problems. I am struck by what the hon. Gentleman is saying. Is he able to talk a bit more about, or perhaps give a comment on, how having such a focus in a service can help children who are the victim of the illness of their parents?

[Andrew Selous]

I am grateful to the hon. Lady for her comments. May I extend to her a very warm invitation to come to the next meeting of the all-party parliamentary group on 6 November when we will consider such issues further? She is absolutely right that these issues are intergenerational. If she was following the example of Mark and Polly, she would have learned that it was their own parents’ stormy relationships that had affected them. Of course their children were suffering deeply from the problems that they were having in their own relationship or marriage. Such issues are deeply related, and she is completely right to say that the children suffer hugely when there are relationship problems between the parents. It is vital that we get this matter right for the children, and I would welcome her support on a cross-party basis on these important issues; they are just too important to be bipartisan about. I would love to have cross-party agreement on the importance of relational issues in public health, because I feel so passionately about the matter.

Another concern is the geographic differences in the ability to get couple therapy through IAPT at the moment. Ruth Sutherland, the chief executive officer of Relate, told me only yesterday that the programme is very geographically bound. Provision is better in the north of England—I note that there are not many colleagues from the north of England in the Chamber today—than in the south, so there is an inequality of access geographically, as well as there being fewer of these sessions available across the UK as a whole.

Let me make one further point to the Minister about why one part of IAPT provision is an incredibly serious matter for the whole NHS. As a clinician, he will know about the huge importance of long-term conditions, which are faced by so many of our constituents. He will be well aware of the significant demands that they will make on the NHS in years to come. I am talking about strokes and dementia and all sorts of other long-term ailments that many of our constituents will live with for a very long time.

I heard a moving story a couple of weeks ago from a gentleman who was visiting his elderly parents in Manchester. He said that between them as a couple they could function. Between the two of them, they had one pair of eyes, ears and legs that worked. They were both sick in different ways. They could cope and look after each other, but what would have happened if they had split in younger years? They might have been like Polly and Mark and had difficulties and not been able to receive the type of help that I have outlined. Let us say that they did sadly split up, like so many couples do today. They would be in two different flats in different parts of Manchester needing far more help from their GP and far more adult care, and that would fall on the clinicians for whom the Minister is responsible and on adult social services. Yes, it would have an impact on their families, and we would all be paying more through our taxes and there would greater burdens on business as well from having to look after that couple in two different settings. The importance of strong couple relationships in older age, in later life, is critical not least to deal with the increase in long-term conditions, which are becoming more and more prevalent and which many of our constituents will be coping with for many years to come. That is my final pitch to the Minister.

We are talking specifically about mental health and IAPT. I understand that a lot of good work is being done under IAPT and that it is an excellent programme, but I ask the Minister, when he goes back to his Department and talks to his colleagues and the Secretary of State, to take back with him the absolute centrality of strong relational health up and down are country as far as public health, the burdens on the NHS and his Department are concerned.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

Sir Edward, it is a pleasure to serve under your chairmanship this morning.

This has been a thoughtful and important debate on a subject that is not talked about nearly enough. Every day in Britain, people of all ages and backgrounds, and from all communities, have their lives blighted by the spectre of mental illness. Theirs are some of the great untold stories of our society. As many hon. Members have already said, the issue of mental health has been swept under the carpet for too long. One in six people are afflicted by mental illness, but all too often they are scared into silence. That is why this discussion is so important.

I also congratulate the hon. Member for Halesowen and Rowley Regis (James Morris) on securing this debate and on the campaigning that he has done on this issue. In addition, I thank him for giving me the opportunity to talk about mental health in my first debate as Labour’s newly appointed shadow Minister with responsibility for public health.

This debate is even more timely because of the news that we have heard on the BBC this morning, to which a number of hon. Members have already referred. Dr Baggaley, the director of medicine at South London and Maudsley NHS Foundation Trust, has said that our mental health services are in “crisis”, following the news—after the BBC made freedom of information requests—that in a little more than two years we have seen the loss of 1,700 mental health beds. I note that the Minister of State, Department of Health, who is the Minister with responsibility for care, said this morning that the situation is “unacceptable” and that the provision must improve. I hope that the Minister who is here in Westminster Hall today will refer to that when he responds to the debate.

We have heard a number of valuable contributions this morning. In responding to the excellent points that have been made, I will cover three broad themes: first, I will reiterate the importance of early intervention; secondly, I will talk about the improving access to psychological therapies programme, including some specific issues about how IAPT needs to work better; and thirdly, I will talk about what we need to do beyond IAPT.

Let me begin with early intervention. As hon. Members have already said, the long-term consequences are clear if we do not tackle mental illness early; indeed, we can already see those consequences right across our society today. We can see them in the workplace, where mental illness is the largest single cause of long-term sick leave; we can see them in our criminal justice system, where 70% of those in our prisons have a mental illness; and we can see them in our economy, where mental ill health costs Britain’s businesses £26 billion every year, or £71 million every day. Also, in our health service, according to the London School of Economics the physical health care necessitated by mental illness costs the NHS an extra £10 billion each year. All those points show why the case for action could not be any clearer.

I am sure that, like myself, many hon. Members will have had experience of constituents coming to them for assistance; indeed, several hon. Members have referred to those experiences in their contributions to the debate. Constituents come to us in deep distress and dire circumstances. However, many of those situations could have been avoided if those people had received specialist treatment for mental illnesses at a much earlier stage. I echo the hon. Member for Halesowen and Rowley Regis, who said that it is absolutely crucial that we look at this issue of early intervention.

That was why in 2007 the last Labour Government launched the IAPT programme, which helped to make respected and evidence-based therapies available to more people than ever before. As we heard in the hon. Gentleman’s opening speech, thousands of people have been helped on that programme so far. Since then, the current Government have continued the programme and extended it to cover more people, which is a welcome step. However, as this debate has made clear, IAPT is still a developing scheme, with areas that are in need of much improvement. So, my second theme is to focus on those areas that require attention, and I would be grateful if the Minister could address them in his closing remarks.

There are three areas in particular that require attention. The first is funding. Spending on IAPT has increased from zero in 2008-09, when the programme was first launched, to £214 million in 2011-12. The Department of Health has also allocated £54 million to improve access to therapies for children and young people, which is a good step. However, it must be noted that Ministers always pledged that IAPT funding would be additional funding and would not replace existing psychotherapy services. Despite those assurances, non-IAPT therapy services have been cut by more than 5%. Funding has fallen from £185 million in 2009-09 to £172 million in 2011-12. What makes that even more worrying is that overall mental health spending has been cut in real terms for the second year in a row.

That real-terms cut has particular resonance when it comes to the second area that requires attention, which is waiting times; again, waiting times have already been mentioned by hon. Members during this debate. NICE’s aim is that patients receive access to evidence-based therapies within 28 days of referral. It is regrettable that this debate falls the day before the latest programme statistics are published. According to the latest figures, however, which are for 2012-13, more people are having to wait longer to start receiving treatment for anxiety or depression.

[Seema Malhotra]

My hon. Friend makes very important points about waiting times and how they have continued, and also about the cuts to services. Given that the number of university students seeking counselling has risen by a third in the last four years, does she agree that it is important to recognise the impact that the drop in funding could be having on vulnerable students, sometimes forcing them to leave university, which can affect the rest of their life? With the number of students in that situation increasing and without data for average waiting times, we must recognise the importance of early intervention and very fast response.

[Luciana Berger]

I thank my hon. Friend for that intervention, and she raises an important issue. There are lots of different groups of people who do not have access to these sorts of services or who have to wait a disproportionate amount of time to access them. We have already heard hon. Members talking about older people who might not be able to access the IAPT programme, and my hon. Friend refers to university students, who do not necessarily fall into the category of children and young people, but who, as young adults, are struggling with leaving home and with financial pressures.

I have not seen any direct research about what effect the current cost of living crisis is having on our population—I hope that there will be some research into that issue—but my experience from my case load as a constituency MP indicates that we have a problem in our society regarding the pressures of life. More people are having to access these services and therefore the services should be available, which makes the issues of waiting times even more relevant.

More than 115,000 people had to wait more than 28 days from referral until their first treatment or therapy session, which was a 19% increase from the previous year. The hon. Member for South West Bedfordshire (Andrew Selous) made the point that this issue is not only about the statistics but the people behind the statistics, who have to go through the trauma of waiting for treatment and suffering the uncertainty of not knowing when it will come.

On Monday, someone contacted me to say that they had been waiting for a year and a half for cognitive behavioural therapy in the Wirral, on Merseyside, and just this morning on BBC “Breakfast”: there was a woman who was interviewed who had had to wait 17 months for talking therapies treatment. Eventually, she had to be sectioned as her condition deteriorated while she waited for treatment. These cases are not unusual— there are too many cases like them—and it pains me to learn of them. According to a report produced by the We Need to Talk coalition of mental health charities and royal colleges, one in five people have been waiting for more than a year to receive treatment. However, the same report found that people who receive treatment within three months are almost five times more likely to be helped back into work by therapy than others who have to wait for one or two years. As another person wrote to me this week, even a six-week wait can seem a whole lot longer if someone is clinically depressed. Just as we focus on waiting times for cancer treatment and other examples of physical care, we must do the same for mental health therapies.

I will repeat the commitment, which my right hon. Friend the Leader of the Opposition made a year ago, that the next Labour Government will rewrite the NHS constitution; that we will strengthen the rights that it grants to patients; that we will create a genuine parity between mental and physical health care; and that we will set down a new right of access to the therapies that we have been talking about this morning. That will mean that mental health patients will be entitled not only to drugs and other medical treatments but to psychological therapies, and they will have the same guarantees on waiting times, professional advice and patient experience.

However, in addition to how long it takes to receive treatment, we need to examine the range of therapies that are available in the first place, which brings me to my third broad theme; again, it is a theme that has been already been referred to by other hon. Members, but it is important to reinforce it and to ask the Minister to respond to it. Different people are affected by different mental health conditions for all sorts of different reasons. That is why we need diverse mental health provision, with a range of therapies, to cater for people with different needs, preferences and personalities. As the hon. Member for Halesowen and Rowley Regis said, only five types of therapy are currently available via IAPT. Moreover, 90% of IAPT funding has gone towards cognitive behaviour therapies, with limited support for other modes of therapy. The United Kingdom Council for Psychotherapy has described this as an

“overwhelmingly manualised and brief approach to therapy that sits at odds with the professional practice of the majority of leading psychotherapists and counsellors.”

We need to look at going beyond basic therapies that help people go about their day-to-day lives more adequately. There needs to be appropriate room for more intense and longer term psychological treatments, so that the underlying causes do not go unaddressed.

The hon. Member for South West Bedfordshire mentioned the need for couples therapies. The hon. Member for Halesowen and Rowley Regis also talked about older peoples’ problems with accessing treatment.

There is a patient choice issue, too. According to a survey of 500 service users by Mind, only 8% of people had a full choice about which therapy they received and just 13% had a choice about where they received therapy. The 8% who had full choice of therapies—a very small number—were, on average, three times happier with their treatment and five times more likely to say that therapy had helped them back into work. As the programme develops, we need to do all we can to ensure that it caters to people’s individual needs.

What needs to be done beyond IAPT? As welcome as IAPT is, we have to remember that the programme currently only aspires to be available to 15% of the population. The programme’s three-year report, published last November, shows that it is currently delivering 45% recovery rates and aims to reach 50% by March 2015. The big question this raises is, what about the other 50% to 55%—the 50% who continue to suffer from conditions, having gone through the IAPT process, but are not eligible for more intensive psychotherapy services under the stepped care model? That question, and this debate, requires an answer that goes far beyond the IAPT programme. It requires ending the artificial dividing lines in our NHS and pursuing a whole person, fully integrated approach to mental, physical, social and care issues, as Labour has indicated, and it demands a complete revaluation of how we, as a country, think about and approach mental health. That is what Labour’s mental health taskforce is looking at, under the expert leadership of Stephen O’Brien, the chair of Barts Health NHS Trust.

General mental health support should not start in hospital or the treatment room. It needs to start in our workplaces, our schools and our communities, even across our kitchen tables and in the conversations we have with one another. There is no reason why we should not be able to talk about mental health and psychological therapies in the same way we do about access to sexual health services, vaccinations or cancer treatment, but we have a long way to go.

I look forward to the Minister’s response. I hope that he will respond to my questions and issues raised by other hon. Members. Returning to my opening comments on today’s news about the crisis in mental health provision and the reduction in the number of beds, the point of our debate is access to services that would prevent people from going into those beds in the first place. However, we hear today that bed capacity is at 100%. I hope that the Minister will mention those issues as well, because they are interlinked.